2013-01-17T16:31:14-06:00 2012-06-30 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2011-07-01 420818642 CENTRAL COMMUNITY HOSPITAL CENT 5632457000 901 DAVIDSON ST NW ELKADER IA 520439015 FRANCES ZICHAL 5632457000 2013-01-16 1 CARMEN KRANTZ P00031958 5635561790 2013-01-16 2011 2016-02-25 16:41:14Z FRANCES ZICHAL 901 DAVIDSON ST NW ELKADER IA 520439015 6250291 0 X WWW.CENTRALCOMMUNITYHOSPITAL.COM X 1961 IA PROVIDE HEALTHCARE SERVICES TO THE SURROUNDING COMMUNITY 8 8 90 37 0 0 50569 150659 5988393 6039963 9815 4315 39861 40364 6088638 6235301 0 0 0 0 2578432 2659091 0 0 23360 3311943 3414638 5890375 6073729 198263 161572 5897745 5897985 565379 389295 5332366 5508690 X TO BE YOUR TOTAL HEALTHCARE CONNECTION 0 0 4856162 6039963 CENTRAL COMMUNITY HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL SERVING RESIDENTS OF CLAYTON COUNTY, IOWA. REQUIREMENTS OF THE IRS COMMUNITY BENEFIT STANDARD FOR TAX-EXEMPT ORGANIZATIONS ARE INTEGRAL TO CENTRAL COMMUNITY HOSPITAL'S CHARITABLE MISSION. CENTRAL COMMUNITY HOSPITAL IS GOVERNED BY AN INDEPENDENT BOARD, WHICH INCLUDES COMMUNITY LEADERS, CONSUMER REPRESENTATIVES AND BUSINESS EXPERTS. THE BOARD HAS A HISTORY OF COMMITMENT TO ACTING WITH THE HIGHEST INTEGRITY. DURING THIS YEAR, THE BOARD WORKED WITH MANAGEMENT TO CONTINUE TO MAKE IMPROVEMENTS TO ASSURE THE ORGANIZATION IS IN COMPLIANCE WITH ALL RULES AND REGULATIONS GOVERNING THE HEALTHCARE INDUSTRY AND NON-PROFIT ORGANIZATIONS.CENTRAL COMMUNITY HOSPITAL MAKES CARE ACCESSIBLE TO THE ENTIRE COMMUNITY IT SERVES. CENTRAL COMMUNITY HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM AND PROVIDES CARE REGARDLESS OF ABILITY TO PAY. CENTRAL COMMUNITY HOSPITAL HAD OVER 996 EMERGENCY VISITS THIS YEAR WITH AN ADDITIONAL 66 OBSERVATION DAYS. THE HOSPITAL WORKS WITH THE CITY OF ELKADER TO PROVIDE EMERGENCY RESPONSE AND EMERGENCY TRANSPORT SERVICES FOR THE LOCAL COMMUNITIES. THIS YEAR THE HOSPITAL PROVIDED 839 DAYS OF INPATIENT CARE AND 8,386 OUTPATIENT VISITS TO THE RESIDENTS IN THE SERVICE AREA. CENTRAL COMMUNITY HOSPITAL PROVIDED CARE AT MANY LEVELS INCLUDING SCU, ACUTE, SKILLED, INTERMEDIATE, SAME-DAY-SURGERY, OBSERVATION, OUTPATIENT, AND REHAB SERVICES. IN ADDITION, CENTRAL COMMUNITY HOSPITAL PROVIDES NON-EMERGENCY SERVICES. THESE SERVICES ARE ACCESSIBLE TO THE COMMUNITY THROUGH PARTICIPATION IN GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID. FINANCIAL COUNSELING IS AVAILABLE TO PATIENTS. CENTRAL COMMUNITY HOSPITAL TAKES ITS MISSION TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE IT SERVES A STEP FURTHER BY REACHING OUT TO MEET THE BROAD HEALTH NEEDS OF THE COMMUNITY. IT STRIVES TO IDENTIFY COMMUNITY NEEDS BEYOND BASIC HEALTHCARE, WORKING COLLABORATIVELY WITH OTHER COMMUNITY ORGANIZATIONS. NEEDS ASSESSMENTS ARE COMPLETED EVERY THREE YEARS AND UPDATED ANNUALLY BY A COUNTY WIDE MULTI-DISCIPLINARY TEAM AND USED TO PRIORITIZE COMMUNITY PROJECTS.THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNTS OF CHARGES FOREGONE WERE $208,194 FOR THE YEAR ENDED JUNE 30, 2012. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR ENDED JUNE 30, 2012 WAS $140,000.IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS, AND FOR SOME SERVICES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED.THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 4856162 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 26 0 1 90 1 0 0 0 0 0 0 0 0 0 0 X 8 8 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X PAT BOREL 5632457000 901 DAVIDSON ST NW ELKADER IA 520439015 ROBERT BODENSTEINER 0.50 X X 0 0 0 JENNIFER COWSERT 0.50 X X 0 0 0 TOM NEUHAUS 0.50 X X 0 0 0 RANDALL JOHNSON 0.50 X X 0 0 0 DIANE ERICKSON 0.50 X 0 0 0 DARWIN WINKE 0.50 X 0 0 0 RUSSELL KNIGHT 0.50 X 0 0 0 BILL REIMER 0.50 X 0 0 0 FRANCES ZICHAL 40.00 X 120122 0 12824 PAT BOREL 40.00 X 82373 0 7711 202495 0 20535 1 0 0 0 MERCY MEDICAL CENTER - DUBUQUE 250 MERCY DRIVE DUBUQUE IA 52001 PURCHASED SERVICES 578960 WAPITI BOX 92 NEWELL SD 57760 ER PHYSICIANS 422269 NORTHERN IOWA THERAPY 1810 4TH ST SW SUITE 103 WAVERLY IA 50677 PT, OT, ST 322475 3 33234 117425 150659 PATIENT SERVICE REVENU 622110 5785131 5785131 SUPPORTING REVENUE 900099 179514 179514 AFFILIATION AGREEMENT 900099 50279 50279 LIFELINE REVENUE 900099 25039 25039 6039963 5629 5629 54040 13676 40364 40364 40364 1314 -1314 -1314 -1314 6235301 6039963 0 44679 224248 224248 1925556 1626948 280083 18525 44877 31510 12941 426 314709 261685 50032 2992 149701 120509 27775 1417 96761 96761 40482 40482 1703676 1637857 65819 2869 2869 136646 36105 100541 151531 151531 101946 99039 2907 1377 1377 2256 2256 453601 453601 74112 74112 PATIENT SUPPLIES 382120 382120 BAD DEBT EXPENSE 151056 151056 116205 52099 64106 6073729 4856162 1194207 23360 963865 816415 2665 2765 649038 706546 79182 89913 190154 182189 8350450 5281175 3319382 3069275 536610 629281 154201 168953 2648 232648 5897745 5897985 364387 359195 60901 30100 140091 0 565379 389295 X 5140932 5315393 191434 193297 5332366 5508690 5897745 5897985 X 161572 14752 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 26015 26015 4021515 1837823 2183692 4302920 3443352 859568 3069275 6235301 6073729 161572 14752 14752 176324 6243799 0 6243799 -8498 -8498 6235301 6087405 13676 13676 6073729 0 6073729 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE, IF APPLICABLE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF CENTRAL COMMUNITY HOSPITAL FOUNDATION 14,752. PART XII, LINE 4B - OTHER ADJUSTMENTS: MONONA CLINIC RENT EXPENSES INCLUDED IN REVENUE ON FORM 990 -13,676. RESTRICTED DONATIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 5,178. PART XIII, LINE 2D - OTHER ADJUSTMENTS: MONONA CLINIC RENT EXPENSES INCLUDED IN REVENUE ON FORM 990 13,676. 1 1 X 1 X 1 X 1 1 1 0 1 1 140000 140000 0.02360 140000 140000 0.02360 1511 13541 13541 0.00230 1 830412 688472 141940 0.02400 875 6296 6296 0.00110 1 2386 850249 688472 161777 0.02740 1 2386 990249 688472 301777 0.05100 389 389 0.00010 7233 7233 0.00120 1716 9405 9405 0.00160 371 731 731 0.00010 2087 17758 17758 0.00300 0 151056 17677 3027773 2997796 29977 X 1 1 1 1 CENTRAL COMMUNITY HOSPITAL

901 DAVIDSON ST NW ELKADER IA 520439015

X X X X CENTRAL COMMUNITY HOSPITAL 1 1 1 150.000000000000 1 200.000000000000 1 X X X X 1 1 X X X X X 1 0 1 X 0 0 PART I, LINE 3C: INCOME CRITERIA AS A % OF US GOVERNMENT POVERTY INCOME GUIDELINES:LESS THAN OR EQUAL TO 150% 0% PAID BY PATIENT151% - 175% 30% PAID BY PATIENT176% - 200% 50% PAID BY PATIENTGREATER THAN 200% 100% PAID BY PATIENTTHERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. CENTRAL COMMUNITY HOSPITAL MAY USE OUTSIDE AGENCIES TO DETERMINE ELIGIBLITY. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE ELIGIBILITY. PATIENTS WHO MEET PRESUMPTIVE ELIBIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. PRESUMPTIVE ELIGIBILITY AWARDS MUST BE 100% DISCOUNTS. OTHER FORMS OF PRESUMPTIVE ELIGIBILITY INCLUDE: ELIGIBLE FOR THE IOWA CARES PROGRAM, BANKRUPTCY, DEATH WITH NO ESTATE RESOURCES, AND TITLE XIX ELIGIBLE AND RECEIVING NON-COVERED SERVICES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST. PART I, LINE 7: CHARITY CARE EXPENSE WAS REPORTED AT COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO WHICH ADDRESSES ALL PATIENT SEGMENTS. MEDICAID IS COST REIMBURSED THEREFORE THERE IS NO COMMUNITY BENEFIT EXPENSE REPORTED. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7F, WERE REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE BACKED OUT OF TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $151,056. PART II: WE MAKE EVERY EFFORT TO HAVE A CONSTANT PRESENCE AT THE COMMUNITY LEVEL TO PROMOTE HEALTH RELATED ACTIVITIES AND REPORT ON THE VALUE A HOSPITAL BRINGS TO A SMALL COMMUNITY. BASED ON OUR HEALTH NEEDS ASSESSMENT, WE ENCOURAGE THE INVOLVEMENT OF ALL COMMUNITY ORGANIZATIONS IN ACTIVITIES TO PROMOTE BETTER HEALTH FOR OUR SERVICE AREA RESIDENTS. WE HAVE A STRONG PRESENCE IN OUR LOCAL SCHOOL SYSTEMS BY DEVELOPING SCHOOL WELLNESS POLICIES AND TRYING TO PROMOTE GOOD HEALTH HABITS AT AN EARLY AGE. CENTRAL COMMUNITY HOSPITAL IS ALSO INVOLVED IN PUBLIC HEALTH EMERGENCY PREPAREDNESS ACTIVITIES INCLUDING DRILLS AND EXERCISES, MISSION HEALTH DRUG PROGRAM, COMMUNITY HEALTH WORK GROUPS, INFECTION CONTROL MEETINGS ON POLICIES AND PROCEDURES, AND NE IOWA LEADERSHIP AND ECONOMIC DEVELOPMENT MEETINGS TO TRY TO CREATE ADDITIONAL EMPLOYMENT OPPORTUNITIES. WE ARE ALSO ACTIVE IN THE NORTHEAST IOWA FOOD AND FITNESS INITIATIVE. PART III, LINE 4: ALL FORMS OF PAYMENT, INCLUDING SELF-PAY, INSURANCE, CONTRACTUAL ALLOWANCES, AND DISCOUNTS, ARE APPLIED TO THE PATIENT'S ACCOUNT BEFORE THE ACCOUNT IS CLASSIFIED AS BAD DEBT. A PAYMENT RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE. CENTRAL COMMUNITY HOSPITAL DOES NOT REFUSE SERVICES TO PATIENTS THAT GENERATE BAD DEBT.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON THE PERCENTAGE OF INCOMPLETE APPLICATIONS. OF THE 94 TOTAL CHARITY CARE APPLICATIONS, 11 WERE NOT COMPLETED AND THEREFORE THE ACCOUNTS WERE WRITTEN OFF TO BAD DEBT. FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROMTHIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: WE MAKE EVERY EFFORT TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IF A PATIENT CANNOT PAY THEIR BALANCE IN FULL IN 30 DAYS, A FINANCIAL COUNSELOR IS AVAILABLE TO DISCUSS PAYMENT OPTIONS. AFTER FINANCIAL ASSISTANCE IS DETERMINED, ANY PERSONAL PORTION DUE FOLLOWS THE SAME DEBT COLLECTION POLICY AS OTHER PATIENTS WITHOUT FINANCIAL ASSISTANCE. IF A BANKRUPTCY NOTICE IS RECEIVED ON ANY ACCOUNT, ALL COLLECTION ACTIVITIES WILL CEASE IMMEDIATELY. CENTRAL COMMUNITY HOSPITAL WILL NOT HARASS A PATIENT FOR THEIR PAST DUE ACCOUNT, NOR MAKE FALSE STATEMENTS TO GET THE PATIENT TO PAY THEIR ACCOUNT. THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. CENTRAL COMMUNITY HOSPITAL MAY USE OUTSIDE AGENCIES TO DETERMINE ELIGIBILITY. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE ELIGIBILITY. PATIENTS WHO MEET PRESUMPTIVE ELIGIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. PRESUMPTIVE ELIGIBILITY AWARDS MUST BE 100% DISCOUNT. OTHER FORMS OF PRESUMPTIVE ELIGIBILITY INCLUDE: ELIGIBLE FOR THE IOWA CARES PROGRAM, BANKRUPTCY, DEATH WITH NO ESTATE RESOURCES, AND TITLE XIX ELIGIBLE AND RECEIVING NON-COVERED SERVICES (REVIEWED CASE BY CASE). CENTRAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 13G: FINANCIAL ASSISTANCE INFORMATION IS PROVIDED IN ALL CORRESPONDENCE REGARDING PATIENT BILLS. PART VI, LINE 2: CENTRAL COMMUNITY HOSPITAL MEETS EVERY SIX MONTHS WITH ALL HEALTH CARE PROVIDERS IN CLAYTON COUNTY TO PREPARE A COUNTY-WIDE HEALTH NEEDS ASSESSMENT, CREATE A PLAN OF ACTION, AND MONITOR IMPLEMENTATION. THIS DOCUMENT IS REVIEWED ANNUALLY AND REWRITTEN EVERY FIVE YEARS. THE NEEDS ASSESSMENT IS UTILIZED BY ALL CLAYTON COUNTY PROVIDERS TO PLAN COMMUNITY PROGRAMS AND LOOK FOR OPPORTUNITIES TO OFFER PROGRAMS FOCUSED ON THE COUNTY-WIDE NEEDS.TO MEET THE 501(R) REQUIREMENTS, THE NEEDS ASSESSMENT WILL BE COMPLETED EVERY 3 YEARS. THE NEEDS ASSESSMENT IS CURRENTLY IN PROCESS AND WILL BE COMPLETED AND POSTED TO OUR WEBSITE BEFORE THE JUNE 30, 2013 DUE DATE. PART VI, LINE 3: AT THE TIME OF REGISTRATIONS, CCH STAFF MAKES EVERY EFFORT TO DETERMINE IF A PATIENT MAY POSSIBLY NEED OR QUALIFY FOR ANY FINANCIAL ASSISTANCE. WE NOTIFY PATIENTS OF THE AVAILABILITY OF THESE PROGRAMS BY POSTING INFORMATION IN OUR REGISTRATION AND EMERGENCY ROOM AREAS. WE OFFER A PRIVATE MEETING WITH A FINANCIAL COUNSELOR. INPATIENTS ARE OFFERED AN OPPORTUNITY TO MEET WITH THE COUNSELOR UPON DISCHARGE. FINANCIAL ASSISTANCE INFORMATION IS PROVIDED IN ALL CORRESPONDENCE REGARDING PATIENT BILLS. OUR FINANCIAL COUNSELOR ATTEMPTS PHONE CONTACT WHENEVER POSSIBLE. OUR "MISSION HEALTH" CHARITY PROGRAM INFORMATION IS AVAILABLE ON OUR WEBSITE. WE DO AN ANNUAL ARTICLE ABOUT THE SERVICE IN OUR NEWSLETTER. OUR FINANCIAL COUNSELOR WILL ALSO ASSIST WITH ENROLLMENT IN EXTERNAL PROGRAMS. PART VI, LINE 4: CENTRAL COMMUNITY HOSPITAL SERVES THE RESIDENTS OF CLAYTON COUNTY. IT IS A RURAL, AGRICULTURAL COMMUNITY. EMPLOYERS IN THE AREA ARE GENERALLY SMALL AND OFTEN DO NOT OFFER EMPLOYEE HEALTH BENEFITS. THE COUNTY HAS ONE OF THE LOWEST INCOME PER CAPITA LEVELS IN THE STATE. RESIDENTS WOULD HAVE TO TRAVEL APPROX. 70 TO 90 MILES TO REACH A LARGER HEALTH FACILITY. THE AREA IS ACCESSED VIA STATE AND COUNTY TWO-LANE ROADS, OFTEN DIFFICULT TO TRAVEL IN THE WINTER.THE 2010 POPULATION FOR CLAYTON COUNTY WAS 18,129. THE 2010 MEDIAN HOUSEHOLD INCOME FOR A FAMILY WAS $40,199. ABOUT 5.70% OF FAMILIES AND 8.60% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 9.60% OF THOSE UNDER AGE 18 AND 9.40% OF THOSE AGE 65 OR OVER. PART VI, LINE 5: OUR ORGANIZATION HAS A BOARD OF DIRECTORS REPRESENTING THE ENTIRE SERVICE AREA AND WITH VARIED BACKGROUNDS. WE HAVE AN OPEN MEDICAL STAFF. IN ADDITION TO OUR LOCAL PHYSICIANS, WE ENCOURAGE SPECIALTY PHYSICIANS TO HOLD CLINICS AT OUR FACILITY TO IMPROVE ACCESS TO OUR LOCAL RESIDENTS. WE HAVE MADE GREAT EFFORTS TO MINIMIZE LONG-TERM DEBT AND INSTEAD TAKE THE APPROACH OF REINVESTING CASH FLOW BACK INTO THE ORGANIZATION. PART VI, LINE 6: CENTRAL COMMUNITY HOSPITAL IS AFFILIATED WITH MERCY MEDICAL CENTER - DUBUQUE, A PRIVATE, NON-PROFIT ORGANIZATION. THE HOSPITAL ENTERED INTO A MASTER AFFILIATION AGREEMENT WITH MERCY MEDICAL CENTER - DUBUQUE TO PROVIDE HOSPITAL, PHYSICIAN, AND OTHER HEALTH CARE SERVICES IN ELKADER, IOWA. MERCY IS COMMITTED TO SUPPORTING HEALTH CARE IN RURAL AREAS, AS DEMONSTRATED BY THEIR JOINT OPERATIONS AND SUBSIDY OF MEDICAL CLINICS AS WELL AS THEIR RURAL OUTREACH PROGRAMS. REPORTS FILED WITH STATES PART VI, LINE 7 IA FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD. THE PRESIDENT OF THE BOARD CHAIRS THE COMMITTEE. THE COMMITTEE HAS AND MAY EXERCISE THE POWER AND AUTHORITY OF THE BOARD WHEN NECESSARY OR ADVISABLE BETWEEN THE MEETINGS OF THE BOARD. THE COMMITTEE REPORTS ALL OF ITS ACTIONS TO THE BOARD AT THE NEXT REGULAR OR SPECIAL MEETING OF THE BOARD, AND SUCH ACTIONS ARE SUBJECT TO REVISION AND ALTERATION BY THE BOARD AT SUCH MEETING; PROVIDED HOWEVER, THAT THE RIGHTS OF THIRD PARTIES ARE NOT AFFECTED BY ANY SUCH REVISION OR ALTERATION. FORM 990, PART VI, SECTION A, LINE 2 FRAN ZICAL, CEO, AND RUSSEL KNIGHT, BOARD MEMBER, HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 FRAN ZICHAL, CEO, IS EMPLOYED BY MERCY MEDICAL CENTER - DUBUQUE. CENTRAL COMMUNITY HOSPITAL HAS A MASTER AFFILIATION AGREEMENT WITH MERCY MEDICAL CENTER - DUBUQUE. THE BOARD OF DIRECTORS OF THE REPORTING ORGANIZATION RETAINS ALL AUTHORITY OVER DECISIONS MADE. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS MEMBERS, ALL OF ONE CLASS AND ARE RESIDENT CITIZENS OF THE CENTRAL COMMUNITY HOSPITAL SERVICE AREA. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE BOARD ARE ELECTED BY THE RESIDENT CITIZENS OF THE CENTRAL COMMUNITY HOSPITAL SERVICE AREA AT THE ANNUAL MEETING TO SERVE FOR A TERM OF FOUR YEARS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS MADE AVAILABLE TO ALL BOARD MEMBERS BEFORE IT IS FILED. THE CEO AND CFO REVIEW AND APPROVE THE 990. FORM 990, PART VI, SECTION B, LINE 12C ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY BOARD MEMBER AND OFFICER IS DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY INDIVIDUAL HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND SHOULD NOT BE COUNTED IN DETERMINING THE QUORUM FOR THE MEETING, EVEN WHERE PERMITTED BY LAW. THE MINUTES OF THE MEETING REFLECT THE DISCLOSURE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. ANY NEW MEMBER OF THE BOARD WILL BE ADVISED OF THIS POLICY UPON ENTERING ON THE DUTIES OF OFFICE. THE GOVERNING BOARD, CEO AND CFO COMPLETE AND SIGN THE CONFLICT OF INTEREST FORM YEARLY. THE FORMS ARE REVIEWED BY THE BOARD PRESIDENT AND IF A POTENTIAL CONFLICT IS IDENTIFIED THE BOARD PRESIDENT FOLLOWS UP. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING COMPENSATION FOR THE CEO IS BASED ON SALARY ADJUSTMENT RECOMMENDATIONS BASED ON AN ANNUAL EVALUATION, USE OF WAGE SCALES, COMMITTEE APPROVAL (BOARD CHAIR AND MERCY MEDICAL CENTER - DUBUQUE'S CEO), AND BOARD APPROVAL. ALSO, MERCY MEDICAL CENTER - DUBUQUE'S COMPENSATION SYSTEM IS UTILIZED. THIS INCLUDES REVIEW OF WAGES IN COMPARISON TO COMPARABLE POSITIONS. THE ORGANIZATION DOCUMENTS AND PROVIDES SUBSTANTIATION FOR THEIR COMPENSATION PROCESS FOR THE CEO. THE PROCESS WAS LAST UNDERTAKEN IN FISCAL YEAR 2012. THE HOSPITAL'S BOARD DETERMINES COMPENSATION FOR THE CFO THROUGH AN ANNUAL EVALUATION AND USE OF WAGE SCALES. THE PROCESS IS DOCUMENTED AND WAS LAST UNDERTAKEN IN FY 2012. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON WRITTEN REQUEST. THE FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 AND THEREFORE AVAILABLE FOR PUBLIC INSPECTION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INTEREST IN NET ASSETS OF CENTRAL COMMUNITY HOSPITAL FOUNDATION 14,752. TOTAL TO FORM 990, PART XI, LINE 5: 14,752.